Provider Demographics
NPI:1386895407
Name:PRINCE, JOHN D (PA)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:D
Last Name:PRINCE
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:JOHN
Other - Middle Name:DANIEL
Other - Last Name:PRINCE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA
Mailing Address - Street 1:1 MERCADO ST
Mailing Address - Street 2:STE 200
Mailing Address - City:DURANGO
Mailing Address - State:CO
Mailing Address - Zip Code:81301-7308
Mailing Address - Country:US
Mailing Address - Phone:970-382-9500
Mailing Address - Fax:
Practice Address - Street 1:1 MERCADO ST
Practice Address - Street 2:STE 200
Practice Address - City:DURANGO
Practice Address - State:CO
Practice Address - Zip Code:81301-7308
Practice Address - Country:US
Practice Address - Phone:970-382-9500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-07
Last Update Date:2023-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPA.0007004363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPA9104758OtherLICENSE
FLPENDINGMedicaid
FLPENDINGMedicare PIN